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Cindy Chan, MD
Overview
Aortic structure Dilating disease Constricting disease Diagnosis Treatment
Aortic structure
Aortic layers: intima, media and adventitia Medial Lamellar units (layers)
Collagen/elastin composition Most collagen in adventitia (for tensile strength) Most elastin in media (for compliance)
Matrix degradation
Proteases
Matrix Metalloproteinases MMPs
Eg. MMP-1 (collagenase), MMP-2, MMP-9 (elastase)
Protease inhibitors
Eg. a-1 antitrypsin
Inflammation
Inflammatory cell infiltrates
Matrix degradation
Increased collagenase and elastase activity
Defective remodeling
Cellular and matrix proliferation
Natural history
Unpredictable rate of increase Risk of rupture aneurysm diameter
Aortic Diameter
Complications of aneurysms
Rupture Free, anterior rupture Retroperitoneal rupture Rupture into adjacent structures Inferior vena cava: aorto-cava fistula Duodenum: aorto-enteric fistula Thrombosis Acute arterial occlusion (of the aneurysm itself) Embolization Acute arterial occlusion (distally) Compression of adjacent structures Veins, nerves, bowel
Infrarenal AAA
Mortality is 75-90% 5 year rupture risk is related to transverse diameter
< 3 cm 3.5-4.9 cm > 5.0 cm > 6.0 cm > 8.0 cm ~ 0% ~ 5% ~ 25% ( ~20% at 2 years) ~ 40% 75-80%
~ 2/3 of aortic dissections Tear in ascending aorta or arch Younger, inherited connective tissue disease High mortality with medical Rx
~ 1/3 of aortic dissections Tear in descending aorta Older patients, chronic hypertension Equivalent early results with medical Rx
Stanford type B
Coronary myocardial infarction Bracheocephalic stroke Spinal paralysis Renal renal failure Mesenteric intestinal infarction Extremity gangrene
Aortic segmental and branch artery involvement in 450 aortic dissections (by autopsy)
From: Hurst and Gore, in Doroghazi and Slater (eds.): Aortic Dissection, McGrawHill, 1983, p 193.
Cryptogenic (hematogenous)
Normal aorta:
Syphilitic (thoracic aorta) Salmonella (abdominal aorta)
Diseased aorta:
GM + organisms (strep / staph) Multiple organisms - fungus mycobacteria - immunocompromized patients
Trauma
IV drug use - direct inoculation Iatrogenic
Saccular configuration Less predictable natural history Expectant management is not appropriate
From: Stanson AW, in Strandness and vanBreda (eds.): Vascular Diseases, Churchill Livingstone, 1994, p 600.
Acquired
Atherosclerosis Radiation Takayasus disease Tumor
Constricting disease
Stenosis - limits maximal flow volume through an artery Symptoms result from ischemia of organs
Resting demands Increased demands
Exercise Emotional stress Digestion
Glagov, et al., N Engl J Med 316:1371, 1987. Zarins, et al., J Vasc Surg 7:386, 1988.
Diagnosis
Symptomatic presentation
Pain Hypotension Ischemia - visceral, extremity, cerebral
Physical Exam
Pulses / bruits Abdominal masses
Imaging
Lumenal - stenoses: - duplex U/S, arteriography Mass - aneurysm/ dissection: - CT, MR, U/S
Treatment
Type B Aortic Dissection
Treatment Goals:
Control propagation of dissection
Reduce arterial pressure (beta-blockade) Success judged by pain relief
Treatment
Dilating diseases
Replacement of weakened wall Control of infection?
Constricting disease
Medical therapy for rare cases Atherosclerosis
Risk factor management Bypass grafts
Endoluminal Grafting
- nitinol supports - thin wall seamless fabric
Meadox Vanguard